How to Have Chronic Care Conversations
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Show notes:
I love caring for patients with chronic conditions now, but it wasn’t always the case. Like so many new grads, I struggled with caring for patients managing chronic conditions -- where to start, how to proceed, feeling like we weren’t making any progress towards “control” of those conditions (diabetes, chronic kidney disease, hypertension, etc).
When I was a new nurse practitioner, I was incredibly focused on diagnostic algorithms and medication management. This, of course, is crucial to know, but isn’t truly what moves the needle in chronic conditions.
How to Have Chronic Care Conversations in Primary Care
In this episode, I cover:
✅ What moves the needle in chronic conditions
✅ Normalize what and why this is so hard
✅ What my dog has taught me about caring for patients (and can help you too)
✅ A practical framework for navigating the management of these conditions
Managing Diabetes, Hypertension & CKD Review
If you'd like support learning about how to manage these three chronic conditions, including medication management, most recent guidelines, when to refer and examples of real-life patient cases, join us for the Managing Diabetes, Hypertension & CKD Review Course. Join the course here
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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So this week's episode is all about chronic care conversations.
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And so the context of what I want to talk about in this episode is that it's
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really common frustration that clinicians have both new and experienced where they're
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feeling like it's just not going anywhere.
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They have a patient who has like diabetes or hypertension that's outside of the goal
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ranges, and it feels like it's just hitting a wall and nothing is changing.
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And so I want to focus in on the types of conversations and ways of having those
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conversations that hopefully will help you be more successful in taking care of those
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patients.
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Before I jump in, though, I've been talking a lot about chronic care over the last
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couple of weeks, and I'm really thrilled to share that I'm launching a brand new
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course about care of chronic conditions, diabetes, hypertension, CKD, all the
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bread and butter of primary care.
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So if you haven't gotten on the wait list for that, it's actually opening up next
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week.
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So it's at realworldnp.com slash courses.
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And so if you're on the wait list, I'll be sending you an email for open
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enrollment, but full transparency.
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That's the only way that you can get into the course is by joining that
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wait list.
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So hop over there and join.
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If you haven't already, we're going to be doing it live together in January.
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And I'm beyond excited.
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It's going to be so fun.
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So anyway, jumping into this topic.
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So when it comes to, so the example, so, so I kind of gave an example already,
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but the example I kind of want to highlight.
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So I'll be working with a new grad, a new nurse, newer nurse practitioner,
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and she'll be, he or she, or they will be working with a patient who has
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diabetes, for example, their A1C is 10, maybe 12.
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Last time it was 11 and it seems like it's either gotten worse, maybe slightly
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better, and they've already had a conversation with them.
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They already have, they're trying to figure out the medications.
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Like what's not working here.
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Is it the medication choices?
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Should I change it?
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Like, why aren't they, are they taking their meds?
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How do I talk to this person?
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Right.
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It's just kind of feels like, where do I even start?
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So using that as an example, the first thing I want to say is that like,
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let's just normalize this experience.
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Number one.
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So when I was a new nurse practitioner, it like, it's a skill.
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It's not just learning the medicine is the actual skill.
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You learn a skill, multiple skills of how to do this job, how to
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conduct your patient visits, how to elicit a history, time management,
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make clinical decisions, trust your clinical judgments, step into this new
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leadership role that has automatically been given to you because of the
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new role that you have, right?
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That's a lot of stuff.
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And when I started as a new grad, I was having the same situations happen.
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I think because I just was so focused on learning the medicine, making
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sure I wasn't making mistakes, learning all of those other skills.
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And it just felt like I had, I just didn't have the mental bandwidth
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to even have these types of conversations.
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I'm going to be talking about in this episode.
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So I just want to normalize that this is a skill.
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This is this, these conversations are an extra skill that we need to
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learn and practice and develops over time.
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So cut yourself some slack, especially if you're a new grad, but
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even if you're not a new grad, it takes time to get comfortable with
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these types of conversations and real talk, the conversations are what
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moves the needle in chronic conditions.
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It's not the medication algorithm.
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It's the conversations.
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Okay.
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So let's, let's do a couple of practical steps, right?
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I love systems.
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I love doing things the same way every time having a method to the madness.
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Right.
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So number one, aside from like giving yourself some slack, right.
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Acknowledging this as a skill.
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And the first thing is about empathy, which might sound like a really
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silly thing to say, because if you're a nurse practitioner or a nurse,
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likely you have to be an empathetic person.
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It's really, I think it would be impossible to do this job without
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having some sort of baseline level of empathy, but what I'm talking about
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more specifically is about the experience of having a chronic condition.
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I think what happens so often, especially like I said, because we're
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still learning how to do this job and learn medicine, we get really
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wrapped up in that and I, but I think the other part of it is, is
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that we have to keep these healthy emotional boundaries with patients.
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So that we can do our jobs, but sometimes it gets a little bit far away from
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the humanity of the person in front of us, because we're so focused on the
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algorithms and the medication choices that it's like, and the frustration
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of like, why isn't this getting better?
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And I understand the risk and why don't they understand the risk?
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Right.
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I hear that a lot from people and we just have to get back into that
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like lived experience of the human-ness that like our job is to be
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clinician and keep track of all this stuff and understand it really well,
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but not everybody is in that place.
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And also they have an entirely full human experience life outside of
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the clinic in between those three months visits, right?
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So I just want to give a couple of examples, right?
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So if you've had a chronic condition or you have a chronic condition,
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or even if you have a close family member or friend that does, maybe
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you know exactly what I'm talking about and it's easier for you to
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remember this, to remind yourself of this, but like, just let's get,
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I just want to give you a couple of examples, right?
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So first thing I personally have had some chronic conditions.
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I've had to make lifestyle modifications because of an illness.
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I've had to take daily medications because of an illness and I hate it.
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I really, really resist it.
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And I know, I like know very deeply that this is what needs to happen.
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I know it, right?
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I've learned this as my profession.
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I'm hopefully approaching expertise in my field, right?
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And I still don't want to do it.
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I just don't.
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And it's just, if you can just imagine thinking about taking a
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medication every day for your, the rest of your life, right?
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And think about checking your blood sugar for the rest of your life and
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thinking about having to go to appointments, having to modify your
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life because of your chronic condition.
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Like you can't just up and go to a restaurant with your
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friends to celebrate an engagement, right?
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Like things like that.
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Like, what does that look like?
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Right.
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And so just thinking about imagining yourself in that, if you
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don't have that experience and just trying to remind yourself,
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this is the context of this visit, right?
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Is that this person is coming to you with all these things in their
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life and probably resistance because they just want, like most people
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just want to live a normal life.
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Like for me, I just want to live a normal life.
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I don't want to have pain, but I just want to live a normal life.
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And I hate making modifications that other people, it feels like
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other people don't have to do, right?
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So anyway, maybe that's TMI, but that's like number one with
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empathy, like specific empathy, reminding yourself of that.
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Number two, I just want to give one more example about empathy.
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And then we'll get into some more practical stuff, but
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I want to give you an example of going to the vet with my dog.
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So I love my dog.
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I'm obsessed with my dog.
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She has this like enormous, like queenly dog bed.
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She has two dog beds, actually one enormous one and one on top.
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She's that cushy, right?
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I love my dog.
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When I go to the vet, I cannot for the life of me, remember
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when her appointments are due.
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When, what va what the vaccine schedule is, what the vaccines are,
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what the medication she's supposed to take, what their names are, the brand,
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the generic, I literally know none of those things.
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They send me a letter in the mail or send me a text or send me an email.
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I go to her appointments.
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I I'm a really good dog.
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Mom, I do really great stuff for her.
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I love her.
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I want to have fun with her.
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I want to have a full, happy, healthy, long life.
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And also for some reason, I want zero to do with veterinary medicine.
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I don't care.
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I just, I don't know why, because I love medicine for humans,
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but for some reason I have absolutely zero motivation to learn
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about any of those things.
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I basically just do what they tell me to do.
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Right.
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Which is a perfect example and helps me be so much more
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empathetic to our patients because I'm like, Oh, right.
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I don't care.
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I mean, I care about my dog and I care that I I'm good at
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giving her the medicine, right?
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The preventative, I think it's for heartworm and I don't know, some
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sort of like tick prevention, flea prevention.
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I think that's what it's for, right?
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But it's two different meds.
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It's changed a million times.
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I just buy a year's worth and we just keep doing our thing.
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And I come back when I'm supposed to.
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Right.
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That's all I do.
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And that's all that matters to me.
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And I don't need to know more.
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And that's what it's like for a lot of our patients.
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And, um, so anyway, hopefully those two examples are just
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helpful reminders for us when we get, especially when we work so hard
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and we're moving so fast and there's so much to learn and it's easy to
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look at facts and information data rather like a one C's or lab
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results or monofilament test results.
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Even right.
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Like it's easy for us to look at data and say, okay, this
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data is not matching up.
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Here's the action that needs to happen.
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Do this.
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Right.
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And it's like, okay, let's remember that we're all humans
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and nobody is a hundred percent ever, ever.
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Right.
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I I'm, I overly applaud patients that tell me they take their
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medicines every day, cause it's hard.
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Even me as a clinician with a deep knowledge of medicine is not
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taking my medication every day.
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I'm like 80, 90%.
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Right.
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I try that's all we can do as patients.
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Right.
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So, so that's the first thing.
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The second thing, the first kind of, so let's recap.
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So the first thing is about giving yourself some slack,
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acknowledging this as a skill.
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Number two is reminders of empathy of the experience, like
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a lived life, human experience of having a chronic condition
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that it never stops.
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It's every day.
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Right.
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And then the third kind of like thing, general topic I'm
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going to talk about or, or theme is talking about, like,
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let's just break this down.
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Like, why is this so hard and what can we do about it?
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So the things I want to highlight about chronic care of
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chronic conditions is that when I'm just like meeting a
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person, this is like a brand new patient to me transferred
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from another provider, or he's just started the clinic, something
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like that, somebody, this person, it's like, there's, for
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example, just, just take diabetes by itself.
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Think about all the data that I need to know that
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you need to know.
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Right.
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So how long have they had this for?
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What medications do they take?
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Um, what complications do they have?
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What symptoms do they have?
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Right.
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That's just baseline information.
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Next level, what do they understand?
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Do they understand their medicines?
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Do they understand the risks and why we care about the blood sugar number?
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Right.
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What do we, why do we care?
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What, uh, are the side effects of that?
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Do they know what dialysis means if you're talking about dialysis, right?
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Because it's a side effect, like renal dysfunction as a side effect
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of diabetes, do they know what that means?
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No idea.
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Right.
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And this is like, this is just one visit looking
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at a brand new person, right?
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So these are all the questions in my mind.
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Um, and then what kind of skills do they have, right?
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Especially with diabetes.
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Have they used a glucometer before?
256
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Did they understand how to use it?
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Do they know how to interpret the results?
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Do they know what symptoms to watch out for?
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Right.
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That's like, that's like a huge, like, just think about that.
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Just like that alone.
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Those are all, when I'm seeing a patient with chronic care, my, I
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endeavor to build a relationship over time, and we're going
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to talk about all that stuff.
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And I actually just want to pause cause I'm getting all worked up, but
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also I want to acknowledge that like chronic conditions are never.
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Okay.
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I never say never, but anything is possible.
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Chronic conditions are not solved in one day, in one visit.
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And I know that's really scary.
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At least it was for me as a new grad where it was like, but they
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need their eye exam and their monofilament and their urine microalbumin.
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What if they were in renal failure right now?
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Right.
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Just ridiculous.
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I mean, it's not, it's not ridiculous, but for the context
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of a patient that I'm thinking about, it's like, no, they didn't.
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00:13:56.520 --> 00:13:57.980
They just had their creatinine done.
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Right.
280
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They're fine.
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00:13:59.580 --> 00:14:03.720
But like, there's so many things to information to gather, so much
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teaching to teach or assess and skills to assess and then teach
283
00:14:08.760 --> 00:14:11.700
and guide and reinforce and remind.
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And then remember again, going back to the fact that they're a full
285
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human and they have maybe children to take care of multiple jobs
286
00:14:19.900 --> 00:14:22.920
that they're working, they're not sleeping well, they have a
287
00:14:22.920 --> 00:14:24.800
sick family member, right.
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00:14:25.320 --> 00:14:28.060
They want to just go to a restaurant and celebrate someone's engagement.
289
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Right.
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And they don't want to think about all these other things.
291
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They just want to be free, you know?
292
00:14:33.740 --> 00:14:37.620
So, so anyway, I just want to set the stage for that of like, like
293
00:14:37.620 --> 00:14:41.880
the, just keeping all of these things in mind to set yourself up for
294
00:14:41.880 --> 00:14:45.060
success, this is not a one-time conversation of like, Hey, your A1C
295
00:14:45.060 --> 00:14:48.440
is 10, we're going to change this med for you by right.
296
00:14:48.540 --> 00:14:50.160
And of course you're not doing that.
297
00:14:50.280 --> 00:14:51.920
I'm that's an exaggeration.
298
00:14:51.920 --> 00:14:56.100
And unfortunately, her medical system is not set up for more like
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00:14:56.100 --> 00:14:57.180
longer visit times.
300
00:14:57.540 --> 00:15:00.740
But my point here is that those are the types of things we need to
301
00:15:00.740 --> 00:15:04.480
know to help people succeed with their chronic condition management.
302
00:15:05.020 --> 00:15:06.820
And we're not going to do it in one day.
303
00:15:07.640 --> 00:15:08.940
We get to do it over time.
304
00:15:09.260 --> 00:15:12.560
So the way that I do it with patients is that we, I do like,
305
00:15:12.680 --> 00:15:15.380
and I talked about this last week, if you didn't catch last week's
306
00:15:15.380 --> 00:15:19.420
episode, um, but about like the systematic approach to chronic care.
307
00:15:19.820 --> 00:15:23.240
Um, so definitely go back and listen to that or watch that on YouTube if you
308
00:15:23.240 --> 00:15:27.600
want, um, but it's about like, what are the bare minimum safety things?
309
00:15:27.600 --> 00:15:28.960
Like that's the first meeting.
310
00:15:29.000 --> 00:15:32.600
And then from there, I kind of tease it down of like understanding
311
00:15:32.600 --> 00:15:33.940
of the side effects, right?
312
00:15:33.940 --> 00:15:35.140
Cause that's like harm reduction.
313
00:15:35.360 --> 00:15:37.140
Number one, make sure that they're safe.
314
00:15:37.460 --> 00:15:38.700
Do they know how to use a glucometer?
315
00:15:39.120 --> 00:15:39.520
Perfect.
316
00:15:40.340 --> 00:15:41.600
Do they have their medications?
317
00:15:41.880 --> 00:15:42.280
Great.
318
00:15:42.740 --> 00:15:43.140
Right.
319
00:15:43.320 --> 00:15:45.800
And then we can go into, do you understand the risks,
320
00:15:45.840 --> 00:15:47.380
the long-term risks of this?
321
00:15:47.380 --> 00:15:50.960
How can we explain it in a way that you understand, right?
322
00:15:51.900 --> 00:15:54.440
The two last things I want to bring up in terms of like these
323
00:15:54.440 --> 00:15:55.960
ongoing conversations, right?
324
00:15:55.960 --> 00:15:56.840
This is not a one-time thing.
325
00:15:56.840 --> 00:15:58.160
This is a developing rapport.
326
00:15:58.380 --> 00:15:59.220
They're on your panel.
327
00:15:59.300 --> 00:16:01.800
You talk to them over months, right?
328
00:16:01.820 --> 00:16:03.100
You can bring them in monthly.
329
00:16:03.920 --> 00:16:05.980
Probably you don't have space in your calendar in your
330
00:16:05.980 --> 00:16:09.500
schedule to do weekly or bi-weekly, but hopefully they can
331
00:16:09.500 --> 00:16:10.780
meet with a diabetes educator.
332
00:16:10.880 --> 00:16:11.960
They can meet with you.
333
00:16:12.200 --> 00:16:14.240
They can meet with one of the nurses, right?
334
00:16:14.260 --> 00:16:17.060
And do these regular check-ins so that you feel like you're giving
335
00:16:17.060 --> 00:16:20.860
safe care and you know that they feel safe too, right?
336
00:16:20.960 --> 00:16:23.580
And as long as you've established safety to start, then
337
00:16:23.580 --> 00:16:25.940
you can start in those next levels of like, how are we
338
00:16:25.940 --> 00:16:27.480
going to get to these shared goals?
339
00:16:27.980 --> 00:16:29.640
Which brings me again to my last few points.
340
00:16:29.660 --> 00:16:33.520
There's a little bit of a wordy episode, but my last two
341
00:16:33.520 --> 00:16:36.120
things that are like really core with having conversations
342
00:16:36.120 --> 00:16:39.840
with patients who have chronic care is understanding what
343
00:16:39.840 --> 00:16:41.020
their life is like.
344
00:16:41.100 --> 00:16:43.460
And I remember when I was a new grad, because I
345
00:16:43.460 --> 00:16:46.520
was so overwhelmed, I would meet with a mentor and she'd
346
00:16:46.520 --> 00:16:47.700
be like, Oh, so who do they live?
347
00:16:47.840 --> 00:16:48.580
Who do they live with?
348
00:16:48.680 --> 00:16:49.440
What kind of work did they do?
349
00:16:49.440 --> 00:16:50.400
Do they have any kids?
350
00:16:50.700 --> 00:16:52.260
Be like, I don't know.
351
00:16:52.400 --> 00:16:56.240
I didn't ask them that it would make me crazy.
352
00:16:56.240 --> 00:16:57.860
Cause I just wanted to talk about diabetes
353
00:16:57.860 --> 00:16:59.060
medication algorithms.
354
00:16:59.380 --> 00:17:02.920
And like now I know, I know, like I'm glad.
355
00:17:03.020 --> 00:17:03.900
I mean, I still tried.
356
00:17:04.000 --> 00:17:06.160
I still was like, okay, that's, I don't have time for that.
357
00:17:06.160 --> 00:17:07.640
Like I'm that's too overwhelming.
358
00:17:07.819 --> 00:17:09.599
How could I possibly have that conversation?
359
00:17:09.839 --> 00:17:11.700
And it also felt a little scary, right?
360
00:17:12.400 --> 00:17:13.140
Um, I don't know.
361
00:17:13.140 --> 00:17:14.420
I just felt very invasive.
362
00:17:14.420 --> 00:17:17.220
And I don't know, it ties into that leadership
363
00:17:17.220 --> 00:17:18.740
role type of thing, right?
364
00:17:19.400 --> 00:17:21.740
Or you kind of just have to be like direct and bold
365
00:17:21.740 --> 00:17:23.140
in your communication sometimes.
366
00:17:23.880 --> 00:17:25.640
But anyway, I understand that now.
367
00:17:25.660 --> 00:17:27.319
Like those are the keys, right?
368
00:17:27.560 --> 00:17:30.240
So I always ask patients just like, like again,
369
00:17:30.480 --> 00:17:33.340
routine muscle memory of like, Oh, so who do you live with?
370
00:17:33.820 --> 00:17:35.120
Are you working right now?
371
00:17:35.120 --> 00:17:35.900
Are you in school?
372
00:17:36.120 --> 00:17:37.340
Oh, what kind of work do you do?
373
00:17:37.580 --> 00:17:38.180
What is that?
374
00:17:38.200 --> 00:17:39.020
What are your like hours?
375
00:17:39.180 --> 00:17:41.700
Like, like, do you work like regular shift night shift
376
00:17:41.700 --> 00:17:43.020
weekend, stuff like that?
377
00:17:43.080 --> 00:17:43.840
How many days a week?
378
00:17:43.840 --> 00:17:46.060
Most people will volunteer that if they're working seven
379
00:17:46.060 --> 00:17:47.600
days a week or overnight, right.
380
00:17:48.700 --> 00:17:50.780
Um, and then, you know, who you live with, like who's
381
00:17:50.780 --> 00:17:53.260
in your family, it doesn't have to take super long,
382
00:17:53.260 --> 00:17:55.880
but it's really informative, right?
383
00:17:55.960 --> 00:17:58.680
And that brings us to the last piece, right?
384
00:17:58.960 --> 00:18:02.420
So this has like been the hardest one for me.
385
00:18:02.660 --> 00:18:05.420
I actually did this as my like capstone project
386
00:18:05.420 --> 00:18:07.620
when I was in grad school, talking about
387
00:18:07.620 --> 00:18:10.460
interventions for, um, I believe African-American
388
00:18:10.460 --> 00:18:15.280
patients with, um, hypertension and what were
389
00:18:15.280 --> 00:18:17.240
the interventions that were the most successful?
390
00:18:17.480 --> 00:18:19.600
I believe I'm pretty sure that was the topic.
391
00:18:19.660 --> 00:18:22.160
And it turns out like of that, of that, you
392
00:18:22.160 --> 00:18:24.720
know, systematic research review, the most
393
00:18:24.720 --> 00:18:27.440
impactful thing, regardless of dietary
394
00:18:27.440 --> 00:18:29.520
interventions or group programs or community
395
00:18:29.520 --> 00:18:30.780
health workers, like there were so many
396
00:18:30.780 --> 00:18:33.660
different, like nursing specific interventions
397
00:18:33.660 --> 00:18:35.560
that I was researching, not just not
398
00:18:35.560 --> 00:18:36.400
medications, right?
399
00:18:36.460 --> 00:18:38.200
Like medications or medications, but we're
400
00:18:38.200 --> 00:18:41.240
talking about nursing specific stuff and it
401
00:18:41.240 --> 00:18:43.960
was motivational interviewing across the board
402
00:18:43.960 --> 00:18:45.760
was the, was like the only effective
403
00:18:45.760 --> 00:18:46.780
thing statistically.
404
00:18:47.600 --> 00:18:49.640
And so I don't know how much you got
405
00:18:49.640 --> 00:18:52.080
into that with school, but it doesn't
406
00:18:52.080 --> 00:18:53.180
have to be fancy.
407
00:18:53.720 --> 00:18:55.840
It doesn't have to be done in this very
408
00:18:55.840 --> 00:18:57.340
exact specific way.
409
00:18:57.720 --> 00:19:00.460
Really all that it takes is humility,
410
00:19:01.180 --> 00:19:03.720
putting your ego aside, having courage,
411
00:19:03.940 --> 00:19:05.960
being brave and asking.
412
00:19:06.680 --> 00:19:08.480
So, you know, just being honest.
413
00:19:08.700 --> 00:19:10.080
So for example, this is, this is how
414
00:19:10.080 --> 00:19:10.920
it goes for me.
415
00:19:11.360 --> 00:19:12.360
So, you know, Mr.
416
00:19:12.480 --> 00:19:14.660
Jones, I'm really concerned about your
417
00:19:14.660 --> 00:19:15.000
health.
418
00:19:15.220 --> 00:19:16.920
I really want to help you achieve your
419
00:19:16.920 --> 00:19:18.500
goals and what you want to do in
420
00:19:18.500 --> 00:19:19.980
your life and stay healthy.
421
00:19:20.980 --> 00:19:23.120
So I I've noticed that we've worked
422
00:19:23.120 --> 00:19:24.420
together for a couple of months.
423
00:19:24.840 --> 00:19:27.100
And my goal for you is that I want
424
00:19:27.100 --> 00:19:29.560
your A1C, your blood sugar test
425
00:19:29.560 --> 00:19:32.220
level to be under six point, it
426
00:19:32.220 --> 00:19:35.320
would be 6.5, right about, or I
427
00:19:35.320 --> 00:19:36.320
would say lower than what it is, right?
428
00:19:36.320 --> 00:19:38.220
You just leave it super simple.
429
00:19:39.420 --> 00:19:41.540
So I want to understand what your
430
00:19:41.540 --> 00:19:43.640
goals are so that I can help you
431
00:19:43.640 --> 00:19:45.900
the best way for your life.
432
00:19:46.140 --> 00:19:47.880
Because what I want doesn't really
433
00:19:47.880 --> 00:19:48.380
matter.
434
00:19:48.800 --> 00:19:50.280
It's about your, you have your
435
00:19:50.280 --> 00:19:51.260
own life, right?
436
00:19:51.540 --> 00:19:53.540
And so I'll say stuff like that.
437
00:19:53.540 --> 00:19:55.680
And I'll just say, you know, if
438
00:19:55.680 --> 00:19:57.180
you're open to it, I'd love to
439
00:19:57.180 --> 00:19:59.340
hear from you what Matt, like
440
00:19:59.340 --> 00:20:00.980
what's important to you about your
441
00:20:00.980 --> 00:20:03.080
diabetes, what's important to what's
442
00:20:03.080 --> 00:20:04.280
most important to you in your life.
443
00:20:04.280 --> 00:20:05.220
What are you worried about?
444
00:20:05.280 --> 00:20:06.520
What are you concerned about?
445
00:20:07.020 --> 00:20:08.880
And like, it's kind of awkward.
446
00:20:09.580 --> 00:20:10.540
Maybe it's just me.
447
00:20:10.660 --> 00:20:12.340
I'm just awkward, but I'll just
448
00:20:12.340 --> 00:20:13.620
like, I'll just fumble my way
449
00:20:13.620 --> 00:20:14.180
through it.
450
00:20:14.220 --> 00:20:15.420
And it's like, you know what?
451
00:20:15.540 --> 00:20:16.900
I'm going to hold onto humility
452
00:20:16.900 --> 00:20:18.060
and I'm going to hold on to
453
00:20:18.060 --> 00:20:19.420
these like highest best intentions
454
00:20:19.420 --> 00:20:20.200
that I have.
455
00:20:20.840 --> 00:20:21.820
And I'm going to get through it.
456
00:20:21.820 --> 00:20:22.800
I'm going to survive and it's
457
00:20:22.800 --> 00:20:23.820
going to be easier next time.
458
00:20:23.840 --> 00:20:24.820
I don't know why this is so
459
00:20:24.820 --> 00:20:25.080
scary.
460
00:20:25.120 --> 00:20:26.280
Maybe this is just me, but if
461
00:20:26.280 --> 00:20:27.360
this is you, let me know.
462
00:20:28.940 --> 00:20:30.540
But it's like these conversations
463
00:20:30.540 --> 00:20:32.280
feel hard, especially when you have
464
00:20:32.280 --> 00:20:33.760
less time in your visits.
465
00:20:34.300 --> 00:20:35.820
But it really goes back to that
466
00:20:35.820 --> 00:20:38.120
point I was making earlier about
467
00:20:38.120 --> 00:20:40.560
like, this is not done today
468
00:20:40.560 --> 00:20:41.740
in visit one visit.
469
00:20:41.740 --> 00:20:44.040
One is safety, safety assessment.
470
00:20:44.380 --> 00:20:45.740
Again, go back to last week's
471
00:20:45.740 --> 00:20:46.080
episode.
472
00:20:46.100 --> 00:20:48.220
If you want to have a systematic
473
00:20:48.220 --> 00:20:49.700
approach to assessing safety and
474
00:20:49.700 --> 00:20:51.640
chronic care visits, but like
475
00:20:52.340 --> 00:20:54.840
safety first, and then like, how
476
00:20:54.840 --> 00:20:57.100
do you like go in a harm reduction
477
00:20:57.100 --> 00:20:59.480
way in your interventions, right?
478
00:20:59.560 --> 00:21:01.640
Do they understand the alarm
479
00:21:01.640 --> 00:21:02.360
signs and symptoms?
480
00:21:02.460 --> 00:21:03.300
Do they know how to check their
481
00:21:03.300 --> 00:21:04.940
blood sugar for diabetes example?
482
00:21:05.940 --> 00:21:08.100
Um, do they, uh, take their,
483
00:21:08.260 --> 00:21:09.440
understand their medications,
484
00:21:09.720 --> 00:21:09.860
right?
485
00:21:09.880 --> 00:21:11.380
Those are like the main things
486
00:21:11.380 --> 00:21:12.120
to start with.
487
00:21:12.160 --> 00:21:13.620
And then you get into those
488
00:21:13.620 --> 00:21:15.960
long-term, you know, long-term
489
00:21:15.960 --> 00:21:17.580
effects, what's going on?
490
00:21:17.600 --> 00:21:18.440
Like, what, how do you
491
00:21:18.440 --> 00:21:19.280
think this is going?
492
00:21:19.420 --> 00:21:20.880
That's, I love that question.
493
00:21:21.100 --> 00:21:22.600
And again, I also love scripts
494
00:21:22.600 --> 00:21:24.120
because it's like less overwhelming
495
00:21:24.120 --> 00:21:26.140
and less, um, I don't know,
496
00:21:26.220 --> 00:21:28.200
scary, but I'll just say to
497
00:21:28.200 --> 00:21:30.000
them like, like what, how do
498
00:21:30.000 --> 00:21:30.800
you think it's going?
499
00:21:31.520 --> 00:21:32.600
What's stressing you out right
500
00:21:32.600 --> 00:21:32.820
now?
501
00:21:32.820 --> 00:21:34.680
What is most important to you?
502
00:21:34.720 --> 00:21:36.480
How can I best help you?
503
00:21:36.560 --> 00:21:36.700
Right.
504
00:21:36.800 --> 00:21:38.080
And we just kind of like figure
505
00:21:38.080 --> 00:21:39.040
it out and see how it goes.
506
00:21:39.060 --> 00:21:40.100
Because like the heart of
507
00:21:40.100 --> 00:21:42.380
motivational interviewing, if you
508
00:21:42.380 --> 00:21:43.420
want to practice that skill and
509
00:21:43.420 --> 00:21:44.340
become an expert in it,
510
00:21:44.340 --> 00:21:44.820
amazing.
511
00:21:45.020 --> 00:21:45.780
I love that.
512
00:21:46.300 --> 00:21:48.020
And also like the point of it
513
00:21:48.020 --> 00:21:49.420
is that we're getting to their
514
00:21:49.420 --> 00:21:50.320
ambivalence, what they're
515
00:21:50.320 --> 00:21:51.880
ambivalent about, and what's
516
00:21:51.880 --> 00:21:53.140
holding them on either side.
517
00:21:53.480 --> 00:21:54.580
The thing that's driving them
518
00:21:54.580 --> 00:21:55.440
forward is like, you know what?
519
00:21:55.520 --> 00:21:57.740
I really want to, I really
520
00:21:57.740 --> 00:21:58.880
want to go to my daughter's
521
00:21:58.880 --> 00:21:59.100
wedding.
522
00:21:59.520 --> 00:22:00.820
I don't want to die before them.
523
00:22:00.860 --> 00:22:01.800
I don't want to lose a foot.
524
00:22:01.800 --> 00:22:02.960
I don't want to go blind.
525
00:22:03.300 --> 00:22:03.900
Right.
526
00:22:04.140 --> 00:22:05.540
And so you work backwards from
527
00:22:05.540 --> 00:22:08.180
there and we talk about how,
528
00:22:08.360 --> 00:22:09.700
how we help them achieve those
529
00:22:09.700 --> 00:22:10.760
goals and what support
530
00:22:10.760 --> 00:22:12.640
structures do they need for
531
00:22:12.640 --> 00:22:13.660
them in their life?
532
00:22:13.660 --> 00:22:14.160
Right.
533
00:22:15.380 --> 00:22:16.720
So anyway, that's, it's not
534
00:22:16.720 --> 00:22:19.180
as neat and tidy as a
535
00:22:19.180 --> 00:22:21.600
algorithm diagnostic approach
536
00:22:21.600 --> 00:22:23.700
for diagnosing a condition,
537
00:22:24.000 --> 00:22:26.600
but honestly, it really is so
538
00:22:26.600 --> 00:22:26.920
crucial.
539
00:22:27.080 --> 00:22:28.340
We have to know the
540
00:22:28.340 --> 00:22:29.440
medication algorithms.
541
00:22:29.920 --> 00:22:30.980
We have to, right.
542
00:22:30.980 --> 00:22:32.680
We have to know how to do
543
00:22:32.680 --> 00:22:34.820
medicine, but we also have to
544
00:22:34.820 --> 00:22:35.660
do this too.
545
00:22:36.040 --> 00:22:37.260
We have to eventually learn
546
00:22:37.260 --> 00:22:38.660
how to do this again, giving
547
00:22:38.660 --> 00:22:40.220
yourself slack, practicing,
548
00:22:40.660 --> 00:22:42.200
being humble, being courageous
549
00:22:43.220 --> 00:22:45.700
and taking up space as the
550
00:22:45.700 --> 00:22:47.600
leader that you now are as a
551
00:22:47.600 --> 00:22:49.980
nurse practitioner, like it
552
00:22:49.980 --> 00:22:55.340
or not you are and just
553
00:22:55.340 --> 00:22:56.540
practicing, right?
554
00:22:56.920 --> 00:22:59.000
And it's easier to practice
555
00:22:59.000 --> 00:23:00.740
when you're a student, by
556
00:23:00.740 --> 00:23:02.060
the way, if you're a student
557
00:23:02.060 --> 00:23:03.460
listening, go ahead and
558
00:23:03.460 --> 00:23:04.360
practice this because you have
559
00:23:04.360 --> 00:23:05.240
time, you don't have the time
560
00:23:05.240 --> 00:23:06.860
crunch and the patients, if
561
00:23:06.860 --> 00:23:07.720
they think you're an idiot
562
00:23:07.720 --> 00:23:09.020
or give you a face that
563
00:23:09.020 --> 00:23:10.200
think that like implies that
564
00:23:10.200 --> 00:23:11.020
they think you're an idiot.
565
00:23:11.240 --> 00:23:12.000
It doesn't actually matter,
566
00:23:12.000 --> 00:23:12.280
right?
567
00:23:12.280 --> 00:23:13.020
Cause you're like, Hey, I'm
568
00:23:13.020 --> 00:23:13.560
a student.
569
00:23:14.120 --> 00:23:15.200
Um, it doesn't actually matter
570
00:23:15.200 --> 00:23:16.120
when you're, when you're a
571
00:23:16.120 --> 00:23:17.540
new grad too, because them
572
00:23:17.540 --> 00:23:18.660
thinking something about you is
573
00:23:18.660 --> 00:23:19.720
a them thing and not a you
574
00:23:19.720 --> 00:23:20.260
problem, right?
575
00:23:20.260 --> 00:23:20.900
If they don't want to work
576
00:23:20.900 --> 00:23:21.780
with you, then they can see
577
00:23:21.780 --> 00:23:22.780
somebody else, right?
578
00:23:23.140 --> 00:23:24.720
But anyway, it feels safer when
579
00:23:24.720 --> 00:23:26.220
you're a student to practice
580
00:23:26.220 --> 00:23:29.000
feeling like an idiot, at
581
00:23:29.000 --> 00:23:30.120
least that's how I feel when
582
00:23:30.120 --> 00:23:31.500
I'm practicing stuff like this.
583
00:23:31.780 --> 00:23:32.980
Um, but yeah, it's been, it's
584
00:23:32.980 --> 00:23:34.020
been several years now.
585
00:23:34.020 --> 00:23:35.940
Um, so I've gotten better and
586
00:23:35.940 --> 00:23:36.460
better at it.
587
00:23:36.460 --> 00:23:37.540
And I've also developed those
588
00:23:37.540 --> 00:23:38.440
kind of like scripted
589
00:23:38.440 --> 00:23:38.920
questions.
590
00:23:40.180 --> 00:23:42.060
So anyway, I hope this was
591
00:23:42.060 --> 00:23:44.700
helpful and, um, definitely,
592
00:23:44.920 --> 00:23:46.260
definitely, definitely, if you
593
00:23:46.260 --> 00:23:48.080
have any interest at all in
594
00:23:48.080 --> 00:23:49.060
joining us to talk about
595
00:23:49.060 --> 00:23:51.520
diabetes, hypertension, or
596
00:23:51.520 --> 00:23:53.360
CKD, I'm beyond excited.
597
00:23:53.480 --> 00:23:54.460
Um, we're going to be doing
598
00:23:54.460 --> 00:23:55.500
that live class.
599
00:23:55.620 --> 00:23:56.980
Doesn't have a fancy name.
600
00:23:56.980 --> 00:23:57.880
I wish it did.
601
00:23:58.140 --> 00:23:59.580
Um, it's just diabetes,
602
00:23:59.580 --> 00:24:01.420
hypertension and CKD review,
603
00:24:01.980 --> 00:24:03.180
talking about medication
604
00:24:03.180 --> 00:24:06.060
algorithms and, um, titration
605
00:24:06.060 --> 00:24:07.680
and clinical just decision
606
00:24:07.680 --> 00:24:10.060
making and when to refer to
607
00:24:10.060 --> 00:24:11.740
specialists and nephrotoxic
608
00:24:11.740 --> 00:24:13.200
meds and whole bunch of stuff
609
00:24:13.200 --> 00:24:13.760
about renal.
610
00:24:13.900 --> 00:24:14.920
Cause I love renal.
611
00:24:15.060 --> 00:24:16.460
Actually, I just, I just,
612
00:24:16.460 --> 00:24:18.220
just a, um, peer reviewer
613
00:24:18.220 --> 00:24:19.440
of a renal chapter in the
614
00:24:19.440 --> 00:24:19.780
textbook.
615
00:24:20.020 --> 00:24:21.020
So I'll be sure to share
616
00:24:21.020 --> 00:24:22.100
that when that comes out.
617
00:24:23.740 --> 00:24:25.220
Anyway, I love renal stuff
618
00:24:25.220 --> 00:24:26.180
and I know it's really tricky.
619
00:24:26.340 --> 00:24:28.520
So if you want to join us,
620
00:24:28.520 --> 00:24:29.600
it's going to be super fun.
621
00:24:29.720 --> 00:24:31.820
Again, that's at realworldnp.com
622
00:24:31.820 --> 00:24:33.960
slash courses is the waitlist
623
00:24:33.960 --> 00:24:34.940
and we're only going to open
624
00:24:34.940 --> 00:24:35.800
it over email.
625
00:24:36.180 --> 00:24:37.740
So get on the waitlist and
626
00:24:37.740 --> 00:24:38.920
then we'll talk about it.
627
00:24:38.920 --> 00:24:40.060
Uh, and you can join us.
628
00:24:40.060 --> 00:24:41.000
It's going to be great.
629
00:24:41.500 --> 00:24:43.380
I hope you have a wonderful,
630
00:24:43.500 --> 00:24:45.380
wonderful rest of your week.
631
00:24:50.400 --> 00:24:52.280
That's our episode for today.
632
00:24:52.440 --> 00:24:53.700
Thank you so much for
633
00:24:53.700 --> 00:24:54.160
listening.
634
00:24:54.580 --> 00:24:55.940
Make sure you subscribe,
635
00:24:56.200 --> 00:24:57.720
leave a review and tell all
636
00:24:57.720 --> 00:24:58.760
your NP friends.
637
00:24:59.100 --> 00:25:00.580
So together we can help as
638
00:25:00.580 --> 00:25:02.080
many nurse practitioners as
639
00:25:02.080 --> 00:25:03.700
possible, give the best care
640
00:25:03.700 --> 00:25:04.500
to their patients.
641
00:25:04.980 --> 00:25:06.080
If you haven't gotten your
642
00:25:06.080 --> 00:25:07.600
copy of the ultimate resource
643
00:25:07.600 --> 00:25:08.940
guide for the new NP,
644
00:25:09.380 --> 00:25:11.620
head over to realworldnp.com
645
00:25:11.620 --> 00:25:12.500
slash guide.
646
00:25:12.880 --> 00:25:14.240
You'll get these episodes
647
00:25:14.240 --> 00:25:15.400
sent straight to your inbox
648
00:25:15.400 --> 00:25:17.100
every week with notes from
649
00:25:17.100 --> 00:25:18.780
me, patient stories and
650
00:25:18.780 --> 00:25:19.600
extra bonuses.
651
00:25:19.840 --> 00:25:21.040
I really just don't share
652
00:25:21.040 --> 00:25:21.760
anywhere else.
653
00:25:22.180 --> 00:25:23.380
Thank you so much again for
654
00:25:23.380 --> 00:25:23.720
listening.
655
00:25:23.860 --> 00:25:25.080
Take care and talk soon.
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